STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT INFORMATION FORM
PAGE 1 OF 20
Agency:
Address:
Gross Revenue >$20M
Agency Federal ID#:
Charities Registration #:
Non-Profit Agency
For-Profit
For-Profit Agency
Public Agency
Budget Period:_____________to____________Agency Fiscal Year End:____________
Schedules Completed: 1
2
3
4
5
6
Cash Basis
Accrual Basis
Phone:
Chief Executive Officer:
Prepared By:
Contracting Division
DCF
Date:
Contract #
11ABCD
Division Use Only
Program Name
Reimbursable Ceiling
Type of Service
$5,000,000
Contract Type
CR
Budget: I certify that the cost data used to prepare this contract budget is current,
complete, and in accordance with the governing principles for determining costs.
Payment Method
Division Contact Person
Provider Agency
Contact Person and Telephone #
Installment
Expenditure Report: I certify that the expenditures reported herein are curent, accurate, and in accordance
with the contract budget and the governing principles for determining costs.
Contract #
Effective Dates_________to___________
Division________________________
Agency Authorized Signatory
Fiscal Officer
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE SUMMARY
PAGE 2 OF 20
PURPOSE
Agency: Gross Revenue > $20M
Contract#: 11ABCD
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
INTERIM
FISCAL YEAR END
FINAL
PERIOD COVERED
1
BUDGET CATEGORY
A. PERSONNEL
B. CONSULTANTS AND PROFESSIONAL
FEES
C. MATERIALS AND SUPPLIES
D. FACILITY COSTS
E. SPECIFIC ASSISTANCE TO CLIENTS
F. OTHER
TOTAL
$
I. EQUIPMENT (SCHEDULE 6)
J. TOTAL COST
K. LESS REVENUE (SCHEDULE 2)
L. NET COST
M. PROFIT
N. REIMBURSABLE CEILING
O. UNITS OF SERVICE
P. UNIT COST
3
Program A
342,000
$
4
Program B
40,000
$
5
Program C
30,000
$
6
Program D
25,000
$
7
0
46,000
8
0
0
9
10
UNALLOWABLE
COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
- $
- $
- $
60,000
$
141,000
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
- $
G. GENERAL & ADMINISTRATIVE COST
ALLOCATION
H. TOTAL OPERATING COSTS
2
7/1/10-6/30/11
>>>>>>>>>
$
$
342,000
$
35,250
$
35,250
$
35,250
$
35,250
$
- $
- $
- $
$
75,250
$
65,250
$
60,250
$
81,250
$
- $
- $
- $
60,000
- $
- $
- $
- $
-
$
- $
- $
- $
60,000
- $
- $
- $
- $
60,000
-
- $
- $
75,250
$
- $
$
342,000
$
$
60,000
$
$
282,000
$
75,250
$
65,250
$
60,250
$
81,250
$
- $
- $
- $
$
-
$
282,000
$
75,250
$
65,250
$
60,250
$
81,250
$
- $
- $
-
- $
65,250
$
- $
- $
60,250
$
- $
81,250
(141,000)
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
PERSONNEL
3 OF 20
PURPOSE
BUDGET PREPARATION
Agency: Gross Revenue > $20M
Contract#: 11ABCD
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
7/1/10-6/30/11
A BUDGET CATEGORY: PERSONNEL
Position Title/ Name of Employee
1
2
TOTAL
Position
Date
Hours
Number Employed /Week
Program A
1
Executive Director
1
Jan-10
40
$
191,000
2
Program Director (various)
2
Jan-10
40
$
151,000 $
3
$
-
4
$
-
5
$
-
6
$
-
7
$
-
8
$
-
9
$
-
10
$
-
11
$
-
12
$
-
13
$
-
14
$
-
15
$
-
16
$
-
17
$
-
18
$
-
19
$
-
20
$
-
21
$
-
22
$
-
23
$
-
SUBTOTAL(pg. 1)
$
3
342,000 $
4
Program B
5
Program C
6
7
8
Program D
40,000 $
30,000 $
25,000 $
46,000
40,000 $
30,000 $
25,000 $
46,000 $
- $
- $
9
10
UNALLOWABLE
COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
50,000 $
$
10,000
- $
60,000 $
141,000
141,000
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
PERSONNEL
4 OF 20
PURPOSE
BUDGET PREPARATION
Agency: Gross Revenue > $20M
Contract#: 11ABCD
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
7/1/10-6/30/11
A BUDGET CATEGORY: PERSONNEL
Position Title/ Name of Employee
1
2
TOTAL
Position
Date
Hours
Number Employed /Week
Program A
24
$
-
25
$
-
26
$
-
27
$
-
28
$
-
29
$
-
30
$
-
31
$
-
32
$
-
33
$
-
34
$
-
35
$
-
36
$
-
37
$
-
38
$
-
39
$
-
40
$
-
41
$
-
42
$
-
43
$
-
44
$
-
45
$
-
46
$
-
47
$
-
$
- $
SUBTOTAL(pg. 2)
3
4
Program B
- $
5
Program C
- $
6
7
8
Program D
- $
- $
- $
- $
9
10
UNALLOWABLE
COSTS
GENERAL &
ADMINISTRATIVE
COSTS
- $
- $
-
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
PERSONNEL
Agency: Gross Revenue > $20M
Contract#: 11ABCD
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
7/1/10-6/30/11
A BUDGET CATEGORY: PERSONNEL
Position Title/ Name of Employee
PURPOSE
BUDGET PREPARATION
5 OF 20
1
2
TOTAL
Position
Date
Hours
Number Employed /Week
Program A
48
$
-
49
$
-
50
$
-
51
$
-
52
$
-
53
$
-
54
$
-
55
$
-
56
$
-
57
$
-
58
$
-
59
$
-
60
$
-
61
$
-
62
$
-
63
$
-
64
$
-
65
$
-
66
$
-
67
$
-
68
$
-
69
$
-
70
$
-
71
$
-
72
$
-
73
$
-
74
$
-
$
- $
SUBTOTAL(pg. 3)
3
4
Program B
- $
5
Program C
- $
6
7
8
Program D
- $
- $
- $
- $
9
10
UNALLOWABLE
COSTS
GENERAL &
ADMINISTRATIVE
COSTS
- $
- $
-
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
PERSONNEL
Agency: Gross Revenue > $20M
Contract#: 11ABCD
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
7/1/10-6/30/11
A BUDGET CATEGORY: PERSONNEL
Position Title/ Name of Employee
PURPOSE
BUDGET PREPARATION
6 OF 20
1
2
TOTAL
Position
Date
Hours
Number Employed /Week
3
Program A
4
Program B
5
Program C
6
7
8
Program D
9
10
UNALLOWABLE
COSTS
GENERAL &
ADMINISTRATIVE
COSTS
75
$
-
76
$
-
77
$
-
78
$
-
79
$
-
80
$
-
81
$
-
82
$
-
83
$
-
84
$
-
85
$
-
86
$
-
87
$
-
88
$
-
89
$
-
90
$
-
91
$
-
92
$
-
93
$
-
94
$
-
95
$
-
96
$
-
97
$
-
98
$
-
99
$
-
100
$
-
SUBTOTAL (pg. 4)
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
BUDGET CATEGORY A: EMPLOYEE SUBTOTAL
$
342,000 $
40,000 $
30,000 $
25,000 $
46,000 $
- $
- $
- $
60,000 $
141,000
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
A. PERSONNEL (FRINGE)
PAGE 7 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
7/1/10-6/30/11
BUDGET CATEGORY- A. PERSONNEL--FRINGE
1
LINE ITEM
BASIS FOR ALLOCATION
2
TOTAL
3
Program A
4
Program B
5
Program C
6
Program D
7
0
0
8
9
10
0
UNALLOWABLE
COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
FRINGE SUBTOTAL
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
BUDGET CATEGORY A. PERSONNEL TOTAL
$
342,000 $
40,000 $
30,000 $
25,000 $
46,000 $
- $
- $
- $
60,000 $
141,000
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
B. CONSULTANTS AND PROFESSIONAL FEES
PAGE 8 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
BUDGET CATEGORY- B. CONSULTANTS AND
PROFESSIONAL FEES
LINE ITEM
1
TOTAL
BASIS FOR ALLOCATION
BUDGET CATEGORY B. TOTAL
2
3
Program A
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
4
Program B
-
$
5
Program C
-
$
6
Program D
-
$
7
0
-
$
8
0
-
$
7/1/10-6/30/11
0
-
$
-
9
10
UNALLOWABLE COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
-
$
-
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
C. MATERIALS AND SUPPLIES
PAGE 9 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
BUDGET CATEGORY- C. MATERIALS AND
SUPPLIES
LINE ITEM
BASIS FOR ALLOCATION
BUDGET CATEGORY C. TOTAL
7/1/10-6/30/11
1
2
3
4
5
6
7
8
9
10
TOTAL
Program A
Program B
Program C
Program D
0
0
0
UNALLOWABLE COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
D. FACILITY COSTS
PAGE 10 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
BUDGET CATEGORY D. FACILITY COSTS
LINE ITEM
1
BASIS FOR ALLOCATION
BUDGET CATEGORY D. TOTAL
2
TOTAL
3
Program A
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
- $
4
Program B
- $
5
Program C
- $
6
Program D
- $
7
0
- $
0
- $
- $
7/1/10-6/30/11
8
9
10
0
UNALLOWABLE
COSTS
GENERAL &
ADMINISTRATIVE
COSTS
- $
- $
-
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
E. SPECIFIC ASSISTANCE
PAGE 11 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
BUDGET CATEGORY E. SPECIFIC ASSISTANCE
TO CLIENTS
LINE ITEM
BASIS FOR ALLOCATION
BUDGET CATEGORY E. TOTAL
7/1/10-6/30/11
1
2
3
4
5
6
7
8
9
10
TOTAL
Program A
Program B
Program C
Program D
0
0
0
UNALLOWABLE COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
F. OTHER
12 OF 20
PURPOSE
Agency: Gross Revenue > $20M
BUDGET PREPARATION
Contract#: 11ABCD
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
BUDGET CATEGORY F. OTHER
LINE ITEM
BASIS FOR ALLOCATION
SUBTOTAL(pg.1)
7/1/10-6/30/11
1
2
3
4
5
6
7
8
9
10
TOTAL
Program A
Program B
Program C
Program D
0
0
0
UNALLOWABLE COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
F. OTHER
13 OF 20
PURPOSE
Agency: Gross Revenue > $20M
BUDGET PREPARATION
Contract#: 11ABCD
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
BUDGET CATEGORY F. OTHER
LINE ITEM
BASIS FOR ALLOCATION
7/1/10-6/30/11
1
2
3
4
5
6
7
8
9
10
TOTAL
Program A
Program B
Program C
Program D
0
0
0
UNALLOWABLE COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
SUBTOTAL(pg. 2)
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
BUDGET CATEGORY F. TOTAL
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B: CONTRACT EXPENSE DETAIL
G. GENERAL AND ADMINISTRATIVE COST ALLOCATION
PAGE 14 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
BUDGET CATEGORY G. GENERAL AND
ADMINISTRATIVE COST ALLOCATION
1
2
TOTAL
Total: Categories A-F
$
3
Program A
342,000 $
4
Program B
5
Program C
6
Program D
40,000 $
30,000 $
25,000 $
46,000 $
35,250 $
35,250 $
35,250 $
35,250
7
0
0
- $
- $
7/1/10-6/30/11
8
9
10
0
UNALLOWABLE
COSTS
GENERAL &
ADMINISTRATIVE
COSTS
- $
60,000 $
141,000
>>>>>>>>>
General and Administrative Costs
$
$
(141,000)
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B
SCHEDULE 1-COST ALLOCATION DATA
PAGE 15 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
ALLOCATION BASE
$
1
2
3
4
5
6
7
8
9
TOTAL
Program A
Program B
Program C
Program D
0
0
0
UNALLOWABLE COSTS
-
0%
$
0%
$
0%
$
0%
$
0%
$
0%
$
0%
$
0%
$
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
0%
$
PURPOSE
0%
7/1/10-6/30/11
10
GENERAL &
ADMINISTRATIVE
COSTS
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B
SCHEDULE 2-REVENUE
PAGE 16 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
1
DESCRIPTION
Sources other than DCF/DHS
Contracts
Total K. Revenue
2
TOTAL
Program A
$
60,000
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
3
60,000 $
Supporting documentation is required to substantiate the allocations.
4
Program B
-
$
5
Program C
-
$
$
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
6
Program D
-
PURPOSE
7
0
-
$
8
0
-
$
0
-
$
-
7/1/10-6/30/11
9
10
UNALLOWABLE COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
60,000
$
60,000
$
-
DHS (REV 7/86)
Agency: Gross Revenue > $20M
Contract#: 11ABCD
DESCRIPTION OF CREDIT/INCOME
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B
SCHEDULE 3-APPLICABLE CREDITS
PAGE 17 OF 20
AMOUNT
TREATMENT (EXPENSE ITEM OR CATEGORY OFFSET)
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
EXPLANATORY NOTES
7/1/10-6/30/11
DHS (REV 7/86)
Agency: Gross Revenue > $20M
Contract#: 11ABCD
NAME OF RELATED ORGANIZATION
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B
SCHEDULE 4 - RELATED ORGANIZATION
PAGE 18 OF 20
TYPES OF SERVICES, FACILITIES AND/OR SUPPLIES
FURNISHED BY THE RELATED ORGANIZATION
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
EXPLAIN RELATIONSHIP
COST
7/1/10-6/30/11
NAME & COLUMN
NUMBER
OF
PROGRAM/COMPONENT
DHS (REV 7/86)
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B
SCHEDULE 5 - DEPRECIATION/USE ALLOWANCE
PAGE 19 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
A
DEPRECIABLE CAPITAL
ASSET ITEMS
B
ACQUISITION
COST
C
EXCLUSIONS
D
E
F
G
ACCUM.
ANNUAL
ADJUSTED COST
DEPREC.
NET BOOK VALUE
DEPREC.
BASIS
REPORTED ON
(COL D MINUS
REPORTED ON
(COL B MINUS
FINANCIAL
COL E)
FINANCIAL
COL C)
STATEMENTS
STATEMENTS
H
ANNUAL USE
ALLOWANCE
7/1/10-6/30/11
I
J
K
INTEREST
EXPENSE
ANNUAL
DEPREC. &
INTEREST
EXPENSE
(COL G + I)
ALLOWABLE DEPREC. /
USE ALLOWANCE
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
STATE OF NEW JERSEY
DEPARTMENT OF CHILDREN AND FAMILIES
ANNEX B
SCHEDULE 6-COST OF EQUIPMENT
PAGE 20 OF 20
Agency: Gross Revenue > $20M
Contract#: 11ABCD
TYPE & DESCRIPTION OF
ITEM
PURPOSE
BUDGET PREPARATION
MODIFICATION BUDGET
EXPENDITURE REPORT
PERIOD COVERED
BASIS OF
ALLOCATION
TOTAL OF EQUIPMENT
7/1/10-6/30/11
1
2
3
4
5
6
7
8
9
10
TOTAL
Program A
Program B
Program C
Program D
0
0
0
UNALLOWABLE COSTS
GENERAL &
ADMINISTRATIVE
COSTS
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
-